acute coronary syndrome presentation: rural emergency...
TRANSCRIPT
John M Gallagher, MDEMS System Medical Director
Wichita/Sedgwick County Kansas
March 15th, 2016
Rural Emergency
Department and
EMS Considerations
Acute Coronary Syndrome Presentation:
• Conflicts:
– None but looking
• Disclosures:
– Vice-Chair of the NAEMSP
Standards and Practice
Committee
– Medical Advisory Committee
of the Kansas Board of EMS
Objectives
• “Discuss the barriers of STEMI care and
the decisions that need to be made in a
rural and EMS environment.”
This is NOT a
review of the
science
My REAL Objectives
• The participants will:
– Become a bit uncomfortable
– Disagree and be a little pissed off
– Question their own practices and policies
– Worry that they might be doing the wrong
thing
– Get defensive
– And in the end, think critically about our work
“Close enough. Let’s go.”
Walk with me…
The Issues
• 911 activation
• Who to send
• On scene/enroute tasks for EMS
• Destination/Intercepts
• 12 Lead Transmission/Interpretation
• Referring Hospital tasks
• Transfer arrangements
• Receiving Center Variability
Just to get us started…
• You’re in the middle of a case while
working in a small referral center with one
doc and two nurses about 45 minutes from
a receiving center.
I’ll catch you up to speed…
What are our objectives?
What are our objectives?
• Make Diagnosis
• Start treatment
• Get to definitive care
• Safety
• Efficiency
• Accuracy
What are our objectives?
• Make Diagnosis
• Start treatment
• Get to definitive care
• Safety
• Efficiency
• Accuracy
Get to Definitive Care
Get to Definitive Care
• What are your thoughts?
• What are the options?
• What threatens to screw up the plan?
• What info do we need to pick a plan?
Who ya gonna call?
50 min
29 min
18 min
13 min
Get to Definitive Care
Get to Definitive Care
Lets do another one
• List the tasks that the ED team has to do
in order to get this patient started and out
the door
ED Tasks
• The Doc: • Nurse/Tech/Staff:
(Get out a sheet of paper…and
borrow a pencil from one of the
prepared kids)
ED Tasks
• The Doc:
– Make Dx
– Communicate to team
– Tell patient (family)
– Write orders
– Destination decision
– Transport decision
– Doc to Doc call
– Transfer certification
– Transport PCS
– Write chart
• Nurse/Tech/Staff:
– Register patient
– Triage
– Perform EKG
– Start IV
– Give meds
– Transfer packet
– Package patient
– Hand off to EMS
– Nurse to nurse call
So we’re starting to get it…
• Lets try a hard one
Lights and Siren?
Lights and Siren?
Lights and Siren?
50 min
29 min
25.5 min
47 min
Keep ‘em comming
Receiving Center
Variability
Keep ‘em comming
• Receiving Center Variability
What do we agree on?
• ASA is good
• Cath is good
What do we disagree on?
• Heparin
– [Bolus and drip] or [just drip]
– [Bolus with max dose] or [full weight based dose]
• Ticagrelor, Plavix, or neither
• Morphine for pain
– Morphine found to increase mortality in NSTEMI
(CRUSADE), not studied in STEMI
• Beta-Blocker
– Oral, IV, none
– What about inferior distribution?
Variability between
facilities (and even
individual docs) prevents
these issues from being
addressed in protocols.
What are we starting to question?
• Time to cath lab
Results:“Despite improvements in
door-to-balloon times,
there was no significant
overall change in unadjusted
in-hospital mortality or in risk-
adjusted in-hospital mortality,
nor was a significantdifference observed in unadjusted 30-day mortality.”
(numerics omitted)
And my favorite…
What do we agree on that doesn’t
make any sense?
The beginning of time
I’ll explain…
I’ll explain…
The Issues
• 911 activation
• Who to send
• On scene/enroute tasks for EMS
• Destination/Intercepts
• 12 Lead Transmission/Interpretation
• Referring Hospital tasks
• Transfer arrangements
• Receiving Center Variability
911 Activation / Who to Send
• How many ambulances are in your
system?
• What’s the time frame between first
responders and the ambulance?
• What are the practice levels of your
various provider levels?
911 Activation / Who to Send
• 17 y/o female with no history and no drug
use calls 911 for chest pain for one hour.
– What is likely wrong with this girl?
– What would your system send?
Emergency Medical Dispatch
911 Activation / Who to Send
• What can your First Responders do for
this girl?
• What can your BLS providers do?
• ALS providers?
Is your crew going to go screaming down
the road with lights and siren running?
Are they going to give this girl an aspirin?
911 Activation / Who to Send
911 Activation / Who to Send
• What can your First Responders do for
this guy?
• What can your BLS providers do?
• ALS providers?
This thought
process answers
the Intercept
question too!
911 Activation / Who to Send
• If this is how you feel, raise your hand.
On scene / Enroute Tasks
• One more time…..What can EMS do?
On scene / Enroute Tasks
• ASA
• EKG
• IV start
• Nitro
• Morphine
• Heparin/Plavix
• Pressors
• Transport
On scene / Enroute Tasks
• ASA
• EKG
• IV start
• Nitro
• Morphine
• Heparin/Plavix
• Pressors
• Transport
Last one!!!
EKG Interpretation/Cath Lab Activation
EKG Interpretation/Cath Lab Activation
• EKG Interpretation
– Paramedic interpretation
– Computer interpretation
– Transmission (Physician interpretation)
• What does your system do?
(Mine does the first two)
EKG Interpretation/Cath Lab Activation
• What’s good enough for cath lab
activation?
(Why?)
Bringing it all together…
• As we build STEMI systems, there are a
whole mess of cause and effect
relationships we need to consider.
Cause and Effect 1/8
they’re gonna get mad at you and say that
you’re an idiot
If you bring up these issues with people
who think they are doing everything right
Cause and Effect 2/8
we will not have resources available for
the next patient who needs us
If we keep sending all levels of EMS to
every call
Cause and Effect 3/8
we will be treating STEMIs in different
clinical timeframes and will cloud our
data
If we focus only on
First Medical Contact
Cause and Effect 4/8
sub standard care will occur in areas with
unusual geography or unique
circumstances
If we write overarching protocols and
mandate that everyone follows them
Cause and Effect 5/8
patients will receive different care
depending on destination and the
referring hospital staff will have to delay
patient care to talk with accepting staff
If receiving hospitals continue to demand
different treatments than each other
Cause and Effect 6/8
we need to be prepared that traditional
EMS tasks might not get completed prior
to arrival at the hospital
If we ask our EMS crews to “load and go”
when they detect a STEMI
Cause and Effect 7/8
our actions will show others that we don’t
believe in a “minutes count” mentality
If we don’t allow field activation of the
cath lab (and bypass of the ED)
Cause and Effect 8/8
we will improve outcomes and
SAVE LIVES!!!
…and last but not least…
If we continue to come together
and work on the hard issues